How To Use CPT Code 51800

CPT 51800 describes a plastic surgical repair procedure performed on the bladder and/or vesical neck. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 51800?

CPT 51800 can be used to describe a plastic surgical repair procedure performed on the bladder and/or vesical neck. This code encompasses various techniques, including anterior Y-plasty, vesical fundus resection, and wedge resection of the posterior vesical neck. The procedure may involve the removal of a portion of the back of the bladder neck.

2. Official Description

The official description of CPT code 51800 is: ‘Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck (anterior Y-plasty, vesical fundus resection), any procedure, with or without wedge resection of posterior vesical neck.’

3. Procedure

1. The provider begins by making an incision in the abdomen to access the bladder and/or vesical neck and urethra.
2. Subcutaneous tissue is dissected, and the muscles are retracted to reach the targeted area.
3. If necessary, the provider removes any damaged portion of the bladder or vesical neck.
4. The provider then reshapes and repairs any defects present using sutures.
5. In some cases, a portion of the bladder neck may be removed to support the repair.
6. An external urinary drainage catheter tube may be placed for temporary urine flow.
7. The provider closes the incision by suturing the layers of tissue together.

4. Qualifying circumstances

CPT 51800 is typically performed on patients with bladder or vesical neck defects or obstructions. The procedure may be necessary to address conditions such as urinary incontinence, bladder outlet obstruction, or bladder neck contracture. It is important to note that this procedure should be performed by a qualified healthcare professional with expertise in plastic surgery and urology.

5. When to use CPT code 51800

CPT code 51800 should be used when a plastic surgical repair procedure is performed on the bladder and/or vesical neck. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the procedure involves additional techniques or modifications, a different CPT code may be more appropriate.

6. Documentation requirements

To support a claim for CPT 51800, the healthcare professional must document the following information:

• Patient’s diagnosis and the need for the surgical repair procedure
• Details of the specific techniques used, such as anterior Y-plasty or vesical fundus resection
• Date of the procedure
• Any additional procedures performed, such as wedge resection of the posterior vesical neck
• Any complications or unexpected findings during the procedure
• Post-operative care instructions and follow-up plans
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 51800, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The procedure should be performed by a qualified healthcare professional with expertise in plastic surgery and urology. It is also important to follow any additional guidelines or requirements set forth by the payer or insurance company.

8. Historical information

CPT 51800 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was added to the Inpatient Only (IPO) list for Medicare reimbursement.

9. Examples

1. A patient undergoes a plastic surgical repair procedure on the bladder and vesical neck to address urinary incontinence.
2. A healthcare professional performs a cystoplasty with anterior Y-plasty to repair a bladder defect in a patient.
3. A plastic surgeon performs a cystourethroplasty to reconstruct the junction between the bladder and urethra in a patient with bladder neck contracture.
4. A urologist performs a cystoplasty with vesical fundus resection to address bladder outlet obstruction in a patient.
5. A patient undergoes a cystoplasty with wedge resection of the posterior vesical neck to repair a bladder defect caused by trauma.